What the Senate bill changes about Obamacare

Warning: This graphic requires JavaScript. Please enable JavaScript for the best experience.

Senate Republican leaders unveiled a new version of their health-care bill on Thursday after the first version failed to get enough support. The bill takes major steps to roll back provisions of the Affordable Care Act, with spending cuts to Medicaid and marketplace subsidies funding a substantial tax cut for the health-care industry.

Compared to the previous bill, it provides fewer tax breaks for the rich, and uses that money to increase funding for high-cost patients, among other things. It also includes an amendment offered by Sen. Ted Cruz (R-Texas), which would allow companies to sell cheaper, bare-bones plans alongside more comprehensive ACA-compliant ones.

A vote could come within the next few weeks. If it passes, it would need to be reconciled with the House’s bill before going to President Trump’s desk.

See what the Senate bill changes about the ACA and the House bill, including all the latest changes marked according to whether they appeal to moderates or appeal to conservatives:

Who would be covered

Under Senate Republicans’ plan, the government would no longer penalize Americans for failing to have health insurance.

ACA

HOUSE BILL

SENATE BILL

ACA

The individual mandate requires most Americans to have health coverage or pay a fine.

HOUSE BILL

Instead of the mandate, insurers would be allowed to impose a 30 percent premium surcharge on consumers who purchase a new plan after letting their previous coverage lapse — incentivizing healthy people to remain insured. States could choose to make this penalty more severe.

SENATE BILL

Instead of the mandate, people who had a break in coverage would have to wait six months before getting new coverage, incentivizing healthy people to stay in the market. Being on a bare-bones plan, as allowed by Cruz’s amendment, counts as a break in coverage.

ACA

The employer mandate requires larger companies to offer affordable coverage to their employees.

HOUSE BILL

The employer mandate would be eliminated.

SENATE BILL

The employer mandate would be eliminated.

ACA

Young adults could stay on their parents’ health insurance plan until they’re 26 years old.

HOUSE BILL

This provision was unchanged.

SENATE BILL

This provision was unchanged.

How they would pay for coverage

The federal health insurance subsidies that help most people with ACA marketplace plans afford their coverage would change. Health care would get substantially less affordable for most of these people, especially those who are poor, unhealthy or old, according to Linda Blumberg of the Urban Institute, Christine Eibner of Rand Corp. and Karen Pollitz of the Kaiser Family Foundation.

ACA

HOUSE BILL

SENATE BILL

ACA

ACA tax credits are primarily based on income, age and geography, which benefits lower- and moderate-income people buying coverage through ACA marketplaces.

HOUSE BILL

Tax credits would be based primarily on age. The amount would not increase when premiums increased, and people living in higher-cost areas would receive no additional money.

SENATE BILL

Tax credits would be primarily based on age, income and geography. But, they could cover a narrower plan, and people would need to make less money than under the ACA to receive them.

ACA

Cost-sharing subsidies were provided to insurers to help some of their ACA customers cover deductibles and co-payments.

HOUSE BILL

These subsidies would end in 2020, although Trump could cut them off earlier.

SENATE BILL

These subsidies would end in 2020, although Trump could cut them off earlier.

ACA

Insurance companies are not allowed to increase someone’s premiums or deny coverage based on preexisting conditions.

HOUSE BILL

States could allow insurers to increase someone’s premiums based on their preexisting conditions if they had a break in coverage. The state would have to set up some other program, such as a high-risk pool, to cover its sickest residents. And the federal government would have its own $8 billion fund to help cover sick people’s high premiums within the individual market.

SENATE BILL

Insurance companies are not allowed to increase someone’s premiums or deny coverage based on preexisting conditions, though states may allow them to not cover costs associated with some conditions. Cruz’s amendment would allow insurance companies to consider preexisting conditions when charging customers, as long as they also offer at least one plan that doesn’t. Experts expect this to drive up costs for sicker people.

ACA

Insurers can charge older customers up to three times as much as they charge younger customers.

HOUSE BILL

Insurers would be able to charge older customers up to five times as much as they charge younger customers. States could change this ratio, although it’s unclear whether it could be higher than 5 to 1.

SENATE BILL

Insurers would be able to charge older customers up to five times as much as they charge younger customers.

ACA

Individuals can contribute up to $3,400 and families up to $6,750 to pretax health savings accounts.

HOUSE BILL

Starting in 2018, individuals could contribute up to $6,550 and families could contribute up to $13,100 to pretax health savings accounts.

SENATE BILL

People can contribute more to their health savings accounts than under the ACA. People could also begin to use their HSAs to pay for premiums.

ACA

The ACA did not create high-risk pools, because there were other protections for pre-existing conditions.

HOUSE BILL

States would receive $130 billion over 10 years through a new Patient and State Stability Fund for high-risk pools and other programs to help sicker people.

SENATE BILL

The stability fund would receive $182 billion over 10 years and would be aimed at reimbursing insurers who take big losses. This is $70 billion higher than the previous version of the bill. The new bill also adds $45 billion to address the opioid epidemic.

Proposed changes to Medicaid

The bill would restructure Medicaid, narrow the program’s eligibility and probably decrease its funding.

ACA

HOUSE BILL

SENATE BILL

ACA

Medicaid is an entitlement program with open-ended, matching federal funds for anyone who qualifies.

HOUSE BILL

Medicaid would be funded by giving states a per capita amount or block grant based on how much each state is spending, not adjusting for rising costs. Overall, this is expected to substantially decrease federal funding, according to the Congressional Budget Office’s report on the plan.

SENATE BILL

Medicaid would be funded by giving states a per capita amount or block grant, beginning in 2021. The amount would grow more slowly than in the House bill, meaning bigger spending cuts overall. The new version of the bill allows states to go over this cap in the case of public health emergencies.

ACA

States can expand Medicaid to cover people making up to 138 percent of the poverty line, and the federal government would cover an outsize portion of their costs.

HOUSE BILL

States would not be able to expand Medicaid after this year. In states that do expand by the deadline, the federal government will pay a smaller portion of the cost for people who sign up after 2019, making the expansion much more expensive for those states.

SENATE BILL

For states that expand Medicaid, the federal government would pay a smaller portion of the cost starting in 2021.

Other key elements of the plans

ACA

HOUSE BILL

SENATE BILL

ACA

Insurers are required to cover certain categories of essential health benefits, such as hospital visits and mental-health care.

HOUSE BILL

States would be allowed to change what qualifies as an essential health benefit.

SENATE BILL

States would be allowed to change what qualifies as an essential health benefit. Under Cruz’s amendment, insurance companies will be able to sell bare-bones plans, as long as they also offer at least one that’s comprehensive. Experts expect this to drive up costs for sicker people.